Knowledge of the Therapeutic Goals of Diabetes Care among Patients with Type 2 Diabetes at a Tertiary Hospital in Ethiopia

Background A comprehensive cardiovascular risk control reduces diabetes-associated complications but achieving the triplet goals (blood glucose, blood pressure (BP), and low-density lipoprotein (LDL-C)) remains a clinical challenge. Patients' knowledge of these diabetes therapeutic goals has been shown to improve glycemic control. However, this is not well studied in Ethiopia. Methods A cross-sectional study was conducted from March to June 2020 in Tikur Anbessa Specialized Hospital among randomly selected 419 patients with type 2 diabetes. Data was collected using a pretested, structured questionnaire. A multivariable binary logistic regression was fitted to identify determinants of knowledge. Results The mean age (±SD) of study participants was 57.4 (±10.8) years and the median duration (IQR) of diabetes was 12 (7, 20) years. A quarter of them achieved fasting glycemic control, a fifth of them attained the A1c goal and only 3% achieved the triple targets. Patients who reported knowing their target goals for BP, fasting blood sugar (FBS), A1C, and LDL-C were 79.5, 77.3, 11.7, and 7.2% respectively. The factors associated with knowledge of the therapeutic goals were longer diabetes duration, increased household income, age, being divorced as compared to married, having no formal education, and primary education. Conclusion The majority of participants knew their BP and FBS targets while only a minority understood their A1c and LDL-C targets. It highlighted the need for the provision of patient-centered diabetes education to improve knowledge of the therapeutic targets.


INTRODUCTION
Diabetes mellitus is a progressive metabolic disorder. It has become one of the fastest-rising global public health challenges with significant morbidity and mortality. Nearly half a billion people (9.3% of adults) are living with diabetes worldwide with over 4 million diabetes-related deaths annually. The majority of diabetes Ethiopia is among the highest hit African countries. The estimated national prevalence of diabetes is 3.2% in adults of age 20-79 years (2). The pooled prevalence of diabetes in Addis Ababa is about 5% (3).
Despite the established benefits of integrated multiple risk factor reduction (including glycemic control, blood pressure optimization, and lipid-lowering therapy) (4,5), achieving these triplet goals remained a global clinical challenge. Achievement of these triple goals of diabetes care concurrently was successful in less than 10% of patients with type 2 diabetes (6)(7)(8).
Effective diabetes self-management and support are foundational for achieving the treatment goals of diabetes care. Patientcentered diabetes education to improve knowledge and self-care improves clinical outcomes and well-being cost-effectively (9).
It has been studied that patients' knowledge of the therapeutic goals of diabetes management improves self-care, medication adherence, and glycemic control. Lack of patients' knowledge of the therapeutic goals has been a strong predictor of poor compliance, suboptimal glycemic level, and inadequate control of other cardiovascular risk factors (10,11). Yet, there is a dearth of information on this topic in Ethiopia. Therefore, this study assessed patients' knowledge of the therapeutic goals of diabetes care that can be used as baseline information for further studies to implement appropriate interventions.

MATERIALS AND METHODS
An institution-based cross-sectional study was conducted at the endocrine clinic in Tikur Anbessa Specialized Hospital (TASH), Addis Ababa, Ethiopia. This clinic provides outpatient services to about 1000 patients with diabetes in a month. It was conducted from March to June 2020.
The study population was patients with type 2 diabetes attending the endocrine clinic in TASH for regular follow-up during the study period. All adult patients with type 2 diabetes with at least one prior visit to the clinic, and diabetes duration of 1 or more years since diagnosis were included.
Epi info version 7 was used to calculate sample size and determined as 422 using the formula to estimate a single population proportion. A simple random sampling technique was used to select the study participants. ODK version 1.25.2 software was used to collect the data along with the KoboToolbox server to store the collected data. Four BSc nurses who were trained on how to use this software collected the data.
Data on socio-demographic and behavioral factors were collected by interview using "WHO STEPS Instrument for Chronic Disease Risk Factor Surveillance" (12). To assess the study participants' knowledge of the therapeutic goals of diabetes, a 21-item knowledge questionnaire was administered. These items were adapted from prior studies in this area (10). Data on clinical and laboratory profiles of the participants were obtained through a review of digital medical records.
The ODK collected data were validated and exported to SPSS 25 for analysis. Descriptive statistics included mean with SD and median with IQR for continuous variables, while frequency and percentage tables were used for categorical data.
Simple cross-tabulation and binary logistic regression analysis were used to study the association of independent variables with the knowledge of the therapeutic goals of diabetes management. Model fitness was checked using the Hosmer-Lemeshow goodness-of-fit test and was found to be fit. First, a bivariable analysis was done to identify the variables associated with the knowledge of the therapeutic goals of diabetes management. Then variables with Pvalue <0.25 in the bivariable analysis were selected as candidate variables and entered together into multivariable analysis to control for confounders. Lastly, variables with a p-value <0.05 in multivariable analysis were considered statistically significant and AOR with 95% CI was estimated to measure the strength of the associations. The result was presented by using text and tables. Ethical considerations: Ethical approval was obtained from the departmental review board of Internal Medicine, College of Health Sciences, Addis Ababa University. Informed consent was obtained from each study participant. Data were analyzed anonymously.

Demographic
characteristics of the respondents: A total of 419 patients participated in this study yielding a response rate of 99%. Two hundred sixteen participants (51.6%) were females. The mean age (±SD) was 57.4 (±10.8) years. The vast majority of the respondents (96.4%) were urban residents. About a third of the patients reported positive family history of diabetes (Table 1).

Clinical characteristics of the respondents:
The median duration of diabetes was 12 years, IQR (7,20 The odds of primary educated participants having good knowledge of therapeutic goals

DISCUSSION
This was the first comprehensive assessment of the knowledge of the three therapeutic goals of diabetes care and its determinant factors amongst type 2 diabetes patients in Ethiopia. It showed that the proportion of patients with a good composite knowledge score was 59.7% with a mean knowledge score of 4.7 ±2.2 points (out of 10).
The patient population analyzed was representative of the patients with diabetes following at TASH. The mean age, sex, duration of diabetes, educational status, and place of residence in prior studies conducted in the TASH diabetes clinic was similar (13,14). The fasting glycemic control level in this study was also similar to a recent survey looking at the achievement of diabetes treatment goals in TASH (16). However, the percentage of patients taking insulin and practice of weekly blood glucose measurements was higher in this study, probably due to the higher likelihood of clinic visits by patients taking insulin than those on oral drugs who were being managed virtually during the beginning of the COVID-19 pandemic.
On the other hand, knowledge of fasting glycemia targets was better than in a previous study in TASH (15). The percentage of patients knowing their FBS target was also higher than that reported by an institution-based crosssectional survey done in Dessie, Ethiopia (17). The differences in educational level and urban residency could contribute to this significant disparity in the knowledge of the FBS target.
Lipid profile measurement and statin use were higher than in previous studies in TASH and Jimma (15,18). Likewise, HbA1c determination is becoming an increasingly utilized tool for glycemic monitoring compared to previous studies in TASH (15,19). This is an encouraging finding indicating successful efforts of care providers availing such laboratory services in public health institutions to improve diabetes care.
Overall, patients' knowledge of BP and FBS targets and their recent levels were far better than that for A1c and LDL-C. These are much in line with those reported by a study conducted in South Carolina and China where the knowledge of the A1c and LDL-C goals was reported by less than one-third of patients while the rest majority were unknowing of their therapy targets (20)(21)(22). The higher familiarity of the respondents with BP and FBS targets and their recent values could be attributed to the fact that these measurements are commonly performed at each clinic visit compared to A1c and LDL-C tests which are less frequently determined. The higher cost and less availability of A1c and LDL-C testing could also contribute to a very low understanding of these tests while automated BP cuffs and glucometers are more accessible.
The multivariable analysis of this study identified five factors as independent determinants of knowledge of therapeutic goals among patients with type 2 diabetes. Good knowledge was found in younger patients, higher educational status, and married individuals. Likewise, increasing monthly household income and a longer duration of diabetes are statistically associated with good knowledge.
The relationship between increasing age and low educational level with poor knowledge was in agreement with studies from China (21,23), Kuwait (24), and Saudia Arabia (25). Age was found to be negatively correlated with diabetes knowledge in these studies. Older patients scored lower in diabetes knowledge. It could be due to increased cognitive impairment and memory loss with increasing age. Besides, patients with higher education tend to have better access to sources of knowledge about diabetes care with fewer barriers to communicating with diabetes educators.
Similar to our study, other researchers have reported better knowledge with a longer duration of diabetes but not with income and marital status (25-28). However, these studies used different instruments that assessed general knowledge about diabetes, not specific to the therapeutic goals. The possible explanation is that patients with a longer duration of diabetes tend to obtain a significant amount of diabetesrelated knowledge over the years.
Attending diabetes education sessions, being a member of the diabetes association, and having a positive family history of diabetes were not associated with good knowledge of the therapeutic goals of diabetes in this study. In western studies, however, these factors were associated with overall diabetes knowledge status (29)(30)(31)(32). Attending diabetes education has also been shown to be positively associated with good diabetes-related knowledge in Ethiopia (28,29). Lack of informing patients clearly about their goals of care during diabetes education sessions could be a possible reason but it needs further assessment.
In comparison to several previous studies done in Ethiopia that evaluated different aspects of diabetes-related knowledge and self-care activities (14,17,33,35), this study confirmed a relevant knowledge deficit among patients with type 2 diabetes about the most relevant, proximate triple markers of diabetes management, namely blood glucose, blood pressure, and blood lipids.
The main limitations of the study are the predominance of participants with higher education from urban areas that may overestimate the knowledge status, the low health literacy level often making understanding A1c and LDL-C difficult, and being a singlecentered study.
In conclusion, the majority of participants reported knowing their BP and FBS targets while only a minority of patients understood their A1c and LDL-C values and goals. Overall, the composite knowledge status about the triple therapeutic goals of diabetes care among patients with type 2 diabetes was suboptimal. Age, educational status, marital status, household income, and duration of diabetes were identified as independent determinants of knowledge status. The findings of this study may help to improve diabetes education by targeting the knowledge of the therapeutic goals as achieving goals of diabetes care is difficult without patients knowing these specific targets.

ACKNOWLEDGMENT
The assistance provided by Sr. Tsion Shibru is greatly appreciated.